Search Our Site By using the search you will be taken off of our site. Forms Below, you will find links to every form located on the North Dakota Insurance Department website. If you cannot find what you are looking for, please contact the department. ND Insurance Department State Capitol, Fifth Floor 600 East Boulevard Avenue Bismarck, ND 58505-0320 701.328.2440 - phone 701.328.4880 - fax Additional Resources Resources listed below may use external applications or plug-in program modules. Our Application Information page has helpful information on where to retrieve the plug-in or application. Advisory Board Travel Expense Voucher (SFN 52864) - fillable - Web Link Affidavit (SFN 4795) - fillable - Web Link Agent for Service of Process (SFN 8330) - fillable - Web Link Agent of Process - Attachment A (SFN 17912) - fillable - Web Link Anhydrous Ammonia Storage Facility - Inspection Checklist - Nurse Tank Inspection Items (SFN 51231) - fillable - Web Link Annual Statement for an Insurance Premium Finance Company (SFN 16824) - fillable - Web Link Application for Administrator-Certificate of Registration (SFN 16853) - Fillable - Web Link Application For Certification of Exemption to Issue Gift Annuities (SFN 17914) - fillable - Web Link Application for Continuing Education Insurance Course - (SFN 10920) - fillable - Web Link Application for Continuing Education Provider Coordinator(SFN 10921) - fillable - Web Link Application for Coverage (SFN 54369) - Fillable - Web Link Application for Individual Reinsurance Intermediary License - Individual - (SFN 18556) - fillable - Web Link Application for Individual Reinsurance Intermediary License (SFN 18556) - Web Link Application for Non-Resident Insurance Producer License (For Individuals and Business Entities) - Web Link Application for Petroleum Tank Release Compensation Fund (SFN 17017) - fillable - Web Link Application for Pharmacy Benefit Manager (Register as administrator) - (SFN 16853) - fillable - Web Link Application for Registration as a Purchasing Group (SFN 53914) - fillable - Web Link Application for Registration as a Risk Retention Group (Foreign) (SFN 53915) - fillable - Web Link Application for Reinsurance Intermediary License - Corporation or Partnership (SFN 18739) - fillable - Web Link Application for Resident Insurance Producer License (For Individual or Business Entities) - Paper Application - Web Link Appointment / Termination (SFN 50291) - fillable - Web Link Boiler Inspection Report (SFN 10706) - fillable - Web Link Building Application (SFN 16259) - fillable - Web Link Certificate of Assuming Insurer AR-1 (SFN 53913) - fillable - Web Link Certification As An Insurer Of Automobile Warranty Contracts (SFN 54357) - Fillable - Web Link Change of Address/Name (SFN 50072) - fillable - Web Link Commercial Blanket Bond (SFN 18777) - fillable - Web Link Commercial Roof Questionnaire - (SFN 52655) - fillable - Web Link Complaint Against a Company (SFN 18956) - fillable - Web Link Complaint Against an Agent (SFN 19050) - fillable - Web Link Consent to Rate Application - NDPC400 (SFN 51683) - fillable - Web Link Continuing Education Summary Report of Compliance (SFN 10924) - fillable - Web Link County Mutual Abstract of Statement (SFN 4805) - fillable - Web Link County Mutual Annual Statement - Fillable Excel spreadsheet - Web Link County Mutual Companies Checklist (SFN 53137) - fillable - Web Link Course Completion Certificate (SFN 10923) - fillable - Web Link Coverage Changes on Current Property Insured (SFN 3380) - fillable - Web Link Crop Insurance Rate Filing (SFN 51682) - Fillable - Web Link Crop Insurance Rate Filing (SFN 51682) - Printable - Web Link Data Processing Questionnaire (SFN 4792) - fillable - Web Link Declaration of Compliance with the Auto Accident Reparations Act (SFN 51663) - fillable - Web Link Electronic Address Change - Web Link Electronic Appointment Renewals - Web Link Electronic Non-Resident Insurance Producer License (for Individuals or Business Entities) - Web Link Electronic Non-Resident License Renewal - Web Link Environmental Consultant Expense Worksheet (SFN 18731) - fillable - Web Link Excavation Expenses Worksheet (SFN 17331) - fillable - Web Link Fire District Reporting Form (SFN 52764) - Web Link Fire Insurance Premiums & Losses (SFN 7832) - fillable - Web Link Fraternal Societies Checklist (SFN 52095) - fillable - Web Link Fraud Reporting Form (SFN 58333) - fillable - Web Link Health Company Abstract of Statement (SFN 53892) - fillable - Web Link Health Entities Checklist (SFN 52094) - fillable - Web Link Individual Health Insurance Data Report (SFN 54182) - Fillable - Web Link Large Group Health Insurance Data Report (SFN 54180) - Fillable - Web Link Legislator Travel Reimbursement Request (SFN 58426) - fillable - Web Link Legislator Travel Request (SFN 58425) - fillable - Web Link Life Company Abstract of Statement (SFN 4803) - fillable - Web Link Life, Accident, and Health Insurers Checklist (SFN 52090) - fillable - Web Link Listing and Labels Request Form (SFN 53798) - fillable - Web Link Loss Prevention Questionnaire - (SFN 53166) - fillable - Web Link LTC Partnership - Issuer Certification (SFN 58600) - fillable) - Web Link A form for insurance companies to submit required certification. See Implemetation Guidelines, Paragraph C. Medical Malpractice Claim Report (SFN 17118) - fillable - Web Link Notice of Claim (SFN 12199) - fillable - Web Link Notice of Course Subsequent Offering (SFN 10926) - fillable - Web Link Notice of Loss (SFN 9576) - fillable - Web Link Petroleum Tank Registration (SFN 17132) - fillable - Web Link Policy, Form and Rate Filing Transmittal-ND1000 (SFN 51679) - fillable - Web Link Premium Finance Application (SFN 16825) - fillable - Web Link Premium Finance Company Balance Sheet (SFN 16836) - fillable - Web Link Premium Tax - Estimated Tax Form (SFN 11051) - Web Link Premium Tax - Reconciled Tax Form (SFN 11050) - fillable - Web Link Prescription Connection for ND Application - (SFN 58370) - Fillable - Web Link Property and Casualty Company Abstract of Statement (SFN 4802) - fillable - Web Link Property and Casualty Insurers Checklist (SFN 52091) - fillable - Web Link Prospective Loss Costs Reference Filing - NDPC300 (SFN 51681) - Web Link Registration of Appointment of Agent for Service of Process (SFN 53916) - fillable - Web Link Renewal Affidavit for Non-admitted Companies (SFN 53446) - fillable - Web Link Renewal Statement (SFN 16354) - fillable - Web Link Segregated Account/Contents of Contract - Attachment B (SFN 17913) - fillable - Web Link SERFF Retaliatory Filing Fee - ND2000 (SFN 51680) - fillable - Web Link Small Group Health Insurance Data Report (SFN 54181) - Fillable - Web Link Statement of Basket Clause Investments (SFN 53144) - fillable - Web Link Storage Facility-Inspection Checklist (SFN 51230) - fillable - Web Link Surplus Line Risks (SFN 4824) - fillable - Web Link Surplus Lines Affidavit (SFN 4818) - fillable - Web Link Surplus Lines Statement Of Taxable Premiums Received On North Dakota Business (SFN 17419) - fillable - Web Link Title Companies Checklist (SFN 52092) - fillable - Web Link Title Company Abstract of Statement (SFN 14755) - fillable - Web Link Uniform Suspected Insurance Fraud Reporting Form - Web Link Utilization Review Agent Certification (SFN 18378) - fillable - Web Link Utilization Review Filing Report (SFN 18332) - fillable - Web Link Viatical Settlement Broker Business Entity Statement (SFN 54042) - fillable - Web Link Viatical Settlement Broker Individual Statement (SFN 50502) - Web Link Viatical Settlement Provider Statement (SFN 54043) - fillable - Web Link Viatical Settlement Provider-Individual Statement (SFN 58686) - fillable - Web Link Voluntary Cancellation - Insurance Producer License (SFN 53881) - fillable - Web Link Individual Producer License Renewal/Continuation Application - Microsoft Word - 135.5KB Current as of Thursday, August 28, 2008 privacy policy  |  disclaimer copyright 2008 North Dakota Insurance Department